This is a rapid publication site that replaces Virtual Grand Rounds in Dermatology (vgrd.org). Please join and feel free to post cases. You can share the URL with friends. Since 2000, VGRD has been a valuable means to share cases in real time from one's home or office. "AND GLADLY WOLDE HE LERNE AND GLADLY TECHE" has served as an enduring and inspirational motto. For more information, see the "About Page."

Thursday, January 19, 2017

Raynaud's with Digital Ulcerations in a Smoker

The patient is a 63-year-old waitress who presents for
evaluation of painful fingertip ulcerations that have been present for ten
months. She has been seen by a number of physicians including the Wound Care
Center. Nothing has helped.She has had
Raynaud’s Disease for 7 – 8 years.She
has been a heavy smoker for decades and has cut down from two packs per day to
1/2 ppd a month or so ago.

Medications: Nifedipine for her fingertip
ulcers without any help.She’s also
taking lisinopril and carvedilol for hypertension. Her ulcerations were treated with Bactrim and
oral clindamycin without effect.

The Examination shows a pleasant articulate woman. She has
markedly erythematous hands that appear somewhat puffy. There are two purulent subungual digital ulcers.

Clinical Photos: (1/16/17)
The erythema was quite dramatic. I should have taken my associate's hand next to the patient's hand for comparison.

IMPRESSION:

Raynaud’s disease with ulcerations. Should we consider
progression to scleroderma?Could this
be Buerger’s Diasease?. Her history of smoking may be significant.

Primary Raynaud's is the most common form of the disorder and is
not connected to an underlying disease or related medical problem. It
is also called Raynaud’s phenomenon.

Secondary Raynaud's is also called Raynaud's phenomenon. This
form is caused by an underlying, or related, problem. Secondary
Raynaud's is less common than the primary form, but it tends to be a
more serious disorder. Symptoms of secondary Raynaud's often first
appear at later ages — around 40 — while people with the primary form
often see symptoms earlier.

PLAN: I had a long discussion with the patient. We talked
about the need to stop smoking and she promised to do so. A prescription for
Bactroban ointment was given and she will be seen back in one week.

With her permission, she is being presented here on VGRD.

Follow-up:
The digital ulceration of the left fifth finger has progressed to distal reabsorption with bone protrusion. X-rays and orthopedic consultation is pending.

Comments of Richard Sontheimer, M.D.These are extended and useful remarks that begin with: "This
patient’s digital ulceration and the puffiness of her fingers
together argue strongly in favor of systemic sclerosis. The fingertip
ulceration in your patient would be highly atypical for isolated benign
Raynaud's disease.
And, Buerger's disease would not typically produce the sausage-like digital swelling," Please read the entire link as it is very helpful.Also see Reference # 3 below.

Abstract: About ten to fifteen percent of the French
population suffer from Raynaud's phenomenon. Most of the time, it is considered
as primary Raynaud's phenomenon, without underlying disease. The aim of this
expert consensus from the "microcirculation group" for the French
Society of Vascular Medicine and the French Society for Microcirculation, was
to define clinical guidelines in patients consulting for Raynaud's phenomenon.
The recommended minimal screening includes clinical examination, nailfold
capillaroscopy and antinuclear antibodies. In particular, the aim of this
screening is to identify patients with a significant risk for scleroderma, who
would need a careful follow up.

Abstract: excerpt “The presence of two or more enlarged
capillaries in one or more fingers showed 83.1% sensitivity and 100%
specificity for SSc. Among patients with SSc with anti-topoisomerase I
antibody, the disease duration correlated negatively with the dermatoscopic
number of enlarged capillaries and hemorrhages. Dermatoscope allows the easy
and rapid identification of capillary nailfold morphological changes in SSc and
should be routinely used for diagnosing SSc.”

Cuticular (eponychial) hemosoderin-containing deposits (CEHD)
are in fact hemosiderin-containing deposits that can reflect the active
inflammatory phase of microvascular injury occuring in autoimmune disorders
such as DM and SSc. CEHD can be visualized and documented at the bedside with
tools commonly available to any dermatologist (portable dermatoscope and
compact digital camera).

4 comments:

Carvedilol may reduce blood flow to hands and feet. This may be exacerbated by smoking as well. The intense erythema of the hands brings to mind erythromelalgia. Has the patient been worked up for lupus?

I have treated several patients with Raynaud's with Botox, injected similarly as for hyperhidrosis. I have an article written on this, and a book chapter. Its not fully clear why it works, but seems to be quite helpful to reduce discomfort and even to heal ulcerations. Worth a try.

Comments of Dr. Cheng-Leng-0ng (Malaysia): Your clinical photo of the terminal wasting of the finger remind me of my systemic sclerosis patient with very similar picture about 30 years ago. She was about forty years old then, a Chinese.She has radiological evidence of terminal tufting. She only responded to soluble aspirin 75mg daily, with partial help. Thank God eventually her disease burnt out itself.

But I would suggest two things first:-1. Her carvedilol has to be switched as beta blockers are contraindicated in Raynaud's Syndrome.2. She has been handled very gently but I suggest she be told off or rather told to off smoking totally to save her fingers and other body parts too.

I agree with topical mupirocin for better healing, to switch to fucidic acid cream when necessary, since she is an outpatient.

We welcome your comments. We endeavor to serve your patients and you. If you want us to respond, please add your name and email address. Some people have trouble uploading comments. In that case, please send comments directly to djelpern@gmail.com. Thank you.